Benefits and Challenges of the Regional Model Partnership

Benefits and Challenges of the Regional Model Partnership Health. Plan and Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, Solano and Trinity Counties December 7, 2017

About Us Mission: To help our members, and the communities we serve, be healthy. Vision: To be the most highly regarded managed care plan in California. Eureka | Fairfield | Redding | Santa Rosa

Our History Eureka | Fairfield | Redding | Santa Rosa

What is the Regional Model? • Eight counties and PHC worked together to prepare the DMCODS Implementation Plan. • Meetings to develop the model have been ongoing for two years. • Affects approximately 285, 000 PHC members. Important considerations - • PHC is the sole managed care plan in the eight counties. • Physical health, mental health (mild to moderate) and SUD provided to all PHC members. Eureka | Fairfield | Redding | Santa Rosa

PHC’s Role in the Regional Model • Responsible for Managed Care functions. • Administration • Enrollment-Related Functions – • Outreach • Call Center/Initial Screening • Compliance officer responsible for fraud prevention • Member Services • Member handbook • Provider directory • Service provision • • Utilization management Prior authorizations for residential Credentialing DMC providers Contracts with network providers • Access – • Provider network adequacy • Access for people with disabilities Eureka | Fairfield | Redding | Santa Rosa

PHC’s Role in the Regional Model • More Managed Care functions handled by PHC • Care Coordination • • Facilitate access to mental health and physical health services Facilitate successful transitions between levels of care Provide training on ASAM criteria and care coordination systems Mulit-party bi-directional ROI • • • Quality management plan Outcome measures PIPs Regional EQRO Site Reviews Provider trainings EBPs, compliance, etc. • Grievance, Appeal, and Fair Hearing Process. • Quality • Systems – • Payment systems • Encounter Data Eureka | Fairfield | Redding | Santa Rosa

How will the Contracts Work? • State/County intergovernmental agreement for all eight counties. • Modified CPE Protocol • Modified rate setting • County/PHC agreements designating PHC for all managed care functions. • PHC/Provider agreements with all providers. Eureka | Fairfield | Redding | Santa Rosa

How will the financing structure work? • PUPM: Per utilizer per month rate will be negotiated for each County with DHCS (rather than fee for service. ) Aligns with fiscal structure for other PHC programs. • Interim Cost Settlement/Final Cost Settlement: Detailed projections are being built into the Fiscal Plan since there will be no cost settlement. • Realignment Contribution by County: PHC will contract with each county for a share of their realignment funds. • Rates negotiated with each provider: PHC will negotiate rates with each provider, whether County or community-based DMC-certified providers. • PHC financial support: The “risk” for the costs of care will be borne by Partnership Health. Plan; i. e. , if the costs exceed estimates, the Plan will absorb the loss. Eureka | Fairfield | Redding | Santa Rosa

Flow of Funds – DMC/ODS 835 -FFS Realignment State/DHCS County Pmt. To Providers 837 -FFS Provider Eureka | Fairfield | Redding | Santa Rosa

Flow of Funds – Regional Model 835 -PUPM State/DHCS Realignment County Partnership Pmt. To Providers 837 -PUPM Provider Eureka | Fairfield | Redding | Santa Rosa

What are the benefits? • Knowledgeable people performing managed care functions. • PHC has the ability to affect other parts of the system such as medical providers. • PHC will be able to coordinate all aspects of healthcare – physical health/mental health/substance use disorder • Overall savings to the healthcare system. • Fiscal and administrative barriers for small counties are mitigated. • Flexibility and innovation. Eureka | Fairfield | Redding | Santa Rosa

What are the challenges? • SUD has not historically functioned within a medical model. • Non-licensed staff providing services • Group services • Providers who have no EHR and work with paper files • Big differences in County issues between very small, and medium counties. • PHC is not a County so sometimes left out of decisions, communication flow, etc. that has historically existed between Counties and the State. • DMC is not the only component of AOD system. Other components which remain with the Counties create added coordination requirements. • SAPT, EPSDT • Prevention • Youth treatment system development • DHCS difficulty integrating alternative payment methodology. Eureka | Fairfield | Redding | Santa Rosa

Next Steps • PHC will develop the new benefit with technical support from the Counties. • Implementation plan has been approved by DHCS; Fiscal plan has not. • Intergovernmental agreements needed for each County. • Contracts between PHC/County and PHC/Providers must be developed. • Other concerns • Criminal justice coordination/impacts, especially prior to being assigned to Partnership. • Impact of new hub and spoke clinics. • Workforce development issues. Eureka | Fairfield | Redding | Santa Rosa

Contact Us Visit: http: //www. partnershiphp. org/Providers/Health. Services/P ages/Drug%20 Medi-Cal/Drug-Medi-Cal-Benefit. aspx Email: Drug. Medi. Cal. PHC@partnershiphp. org Margaret Kisliuk: Mkisliuk@partnershiphp. org Liz Leslie: Lleslie@partnershiphp. org Eureka | Fairfield | Redding | Santa Rosa

Questions? Eureka | Fairfield | Redding | Santa Rosa